Basic Information
| Provider Information | |||||||||
| NPI: | 1316188667 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HOPSITAL OF LAGRANGE COUNTY,INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHIPSHEWANA FAMILY HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CAREW STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 8175 WEST US 20 | ||||||||
| Address2: | |||||||||
| City: | SHIPSHEWANA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465659169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607687432 | ||||||||
| FaxNumber: | 2607687482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | NAFZIGER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP--CFO | ||||||||
| AuthorizedOfficialTelephone: | 2603737008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOPSITAL OF LAGRANGE COUNTY,INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 01061887A | IN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.